Ovarian Cancer
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Ovarian Cancer is the 6th most common cancer in women but the leading cause of gynaecological cancer death. It often presents vaguely ("The Silent Killer") and is diagnosed at an advanced stage (Stage III/IV) with peritoneal spread.
Clinical Scenario: The Bloated Patient
A 62-year-old woman presents to her GP complaining of 'feeling bloated' and needing to pass urine frequently. She has tried Over-the-counter remedies for IBS but they haven't worked. She has lost appetite.
Key Teaching Points
- **Red Flag**: New onset IBS-like symptoms in a woman >50 years is Ovarian Cancer until proven otherwise.
- **Symptom Cluster (BEAT)**: Bloating, Eating difficulty, Abdominal pain, Toilet trouble.
- **Action**: CA-125 blood test and Urgent Ultrasound.
Image Integration Plan
| Image Type | Source | Status |
|---|---|---|
| Management Algorithm | AI-generated | PENDING |
| Ultrasound (Complex Mass) | Web Source | PENDING |
| CT (Omental Cake) | Web Source | PENDING |
| Histology (Serous Ca) | Web Source | PENDING |
[!NOTE] Image Generation Status: Diagrams illustrating the RMI calculation are queued.
Classification of Ovarian Tumours
- Epithelial (90%):
- Serous (High Grade - most common).
- Mucinous, Endometrioid, Clear Cell.
- Germ Cell (<5%):
- Young women (<30). Teratoma (Dermoid), Dysgerminoma.
- Markers: AFP, hCG, LDH.
- Sex Cord Stromal (<5%):
- Granulosa Cell Tumour (Secretes Oestrogen -> PMB).
- Fibroma (Meigs Syndrome: Fibroma + Ascites + Pleural Effusion).
- Age: Peak 60-70 years.
- Risk Factors (Uninterrupted Ovulation):
- Nulliparity.
- Early Menarche / Late Menopause.
- HRT / Obesity.
- Protective Factors (Ovulation Suppression):
- Combined Pill (COCP) - reduces risk by 50% after 5 years use.
- Pregnancy / Breastfeeding.
- Genetics:
- BRCA1/2: Lifetime risk 40-60% (BRCA1) / 10-30% (BRCA2).
- Lynch Syndrome (HNPCC).
- Ovulatory Trauma: Repeated rupture and repair of the ovarian epithelium leads to malignant transformation.
- Origin: Recent evidence suggests High Grade Serous Carcinoma actually originates in the Fimbriae of the Fallopian Tube (STIC lesions) and sheds onto the ovary.
- Spread: Trans-coelomic (seeds throughout peritoneal cavity) -> Omentum ("Omental Cake"), Diaphragm, Liver surface.
The BEAT campaign symptoms:
Late Signs:
- Abdomen: Ascites? Mass arising from pelvis?
- Speculum/Bimanual: Fixed, hard adnexal mass. Pouch of Douglas nodules.
- CA-125:
- Gold standard biomarker.
- False positives: Endometriosis, Fibroids, Pregnancy, PID, Menstruation.
- Transvaginal Ultrasound (TVUS):
- Look for: Solid areas, Multiloculation, Bilaterality, Ascites.
- Risk of Malignancy Index (RMI):
RMI = Ultrasound Score (1 or 3) x Menopausal Status (1 or 3) x CA125 level.- RMI > 200: High risk -> Refer to Gynae-Onc Centre.
- CT Tap: Staging.
- Ascitic Tap: Cytology can confirm malignancy.
Managed in Specialist Centre (MDT).
A. Surgery
The goal is Primary Cytoreduction (Debulking) to R0 (no macroscopic residual disease).
- Procedure: Total Abdominal Hysterectomy + Bilateral Salpingo-Oophorectomy (TAH + BSO) + Omentectomy + Appendicectomy (if mucinous) + Removal of bulky nodes.
- Interval Debulking: If disease is too extensive initially, give 3 cycles of chemo then operate.
B. Chemotherapy
- Standard: Carboplatin + Paclitaxel (Taxol).
- Given Adjuvant (post-op) or Neo-adjuvant.
- Bevacizumab (Avastin): Anti-VEGF monoclonal (for advanced disease with ascites).
C. Maintenance Therapy
- PARP Inhibitors (Olaparib):
- Highly effective in BRCA mutated or HRD positive (Homologous Recombination Deficiency) tumours.
- Synthetic Lethality: Cancer cells can't repair DNA and die.
- Bowel Obstruction: Common cause of death ("Carcinomatosis peritonei").
- Ascites: Needs drainage.
- Stage 1: >90% 5-year survival.
- Stage 3/4: <30% 5-year survival.
- High recurrence rate (>70%).
- NICE NG61: Ovarian Cancer: recognition and initial management.
- ICON Trials: Established chemotherapy protocols.
What are the symptoms? It is notoriously hard to spot. The symptoms are vague – feeling bloated, tummy pain, needing to pee more often, or feeling full after a few bites of food. Because these symptoms are common (like IBS), many women ignore them. The key is if they represent a change for you and are persistent.
Who gets it? It is more common as you get older (over 60). It can run in families (Brangelina gene / BRCA). Factors that stop ovulation (like the pill or having babies) actually protect against it.
How is it treated? Usually a combination of major surgery to remove the womb, ovaries, and all visible cancer, combined with chemotherapy. New "smart drugs" (PARP inhibitors) are now available that can keep the cancer away for longer, especially if you have the gene mutation.
- NICE. Ovarian cancer: recognition and initial management [NG61]. 2011.
- Prat J. Ovarian carcinomas: five distinct diseases with different origins, genetic alterations, and clinicopathological features. Virchows Arch. 2012.
- Moore K, et al. Maintenance Olaparib in Patients with Newly Diagnosed Advanced Ovarian Cancer. N Engl J Med. 2018.